CUBA - Health without wealth

Starved of funding by the US embargo and the Soviet Union's collapse, Cuba has a health service to put its rich northern enemy to shame. Much of the responsibility for this medical miracle is due to the island's transformation into a model of environmental
good practice

It's 5pm Havana-time on the Cuban capital's crescent-shaped Malec—n sea-drive, and a handsome and svelte-looking taxi driver is steering his battered automobile - a 1955 Chevrolet recently refitted with a Lada engine - painfully homewards to a cacophony of unhealthy screeching. Old men cling to fishing lines, young couples kiss on the promenade, and a groupof off-duty nurses stand outside the giant facade of the Hermanos Ameijeiras Hospital trying to hitch a free ride back west through crumbling Vedado.

Welcome to Cuba - land of trade embargoes and clapped out old cars, free healthcare and libidinous young taxi drivers. Forty-six years after a cigar-puffing Fidel Castro first rolled triumphantly into Havana atop a jeep with the dashing Che in tow, Cuba remains famous for its failed politics, questionable human rights record and a transport system stuck incongruouslyin the 1950s. It might come as some surprise, therefore, to discover that - literally speaking - the health of the nation is still in remarkably good shape, particularly in contrast to that of its much larger neighbour, and enemy, to the north. It's hard to resist the comparison. In the US the federal government forks out anaverage $4,178 per person annually on healthcare. In embargostrapped Cuba a tight-fi sted Castro coughs up a paltry $186 per head to fi nance his citizens in a similar way: that's 4 per cent of the US contribution. Nevertheless, defying all logic, the health indices in both countries are almost equitable.

Back in 1978 Castro boldly declared that Cuba wouldbecome a pioneer in Third World medicine, place a doctor in every community, match the health performance of the world's economic giants and provide a realistic challenge to the medical power of the US. He was right on all four counts. Under the dark shadow of a permanent US trade embargo, Cuba, which languishes 172nd on the world's league table of nations' wealth (in between Mongolia and the Central African Republic) subsequently stuck the lion's share of its meagreresources into healthcare. The aim was to match its northern neighbour on every health index from life expectancy to infant mortality rates. Quite remarkably, it did.

With a doctor/patient ratio of 1/170 and a national poolof 30,000 GPs, who skills-wise could knock strips off many of their US counterparts, Castro's health experts have developed a medical research facility that is the envy of many of the world's cash-rich democracies. The list of Cuba's medical achievements can be rattled off like patients at a walk-in clinic: homegrown treatment for more than 15,000 Chernobyl victims, the successful vaccination of 1.5 million Haitian children against measles, the production of the world's first meningitis B vaccine (subsequently licensed by drug multinational GlaxoSmithKline), heart transplant and cancer research programmes, and one of the world's lowest national rates of Aids.

Given such dramatic and ground-breaking results, it would seem obvious that the rest of the world would be queuing up to learn from the Cuban experience. But they're not. So why, instead of constantly lambasting the Castro regime for political reasons, doesn't the developed world divert its energy into trying to emulate a health system that manages resources, eliminates waste and remains free to everyone, and which does that against all odds?

'Healthcare is better now because we can do more withless,' commented Cuba's understandably smug health minister Leoncio Padron in 1998. Padron's statement was a truism of sorts. Thanks mainly to the ongoing US embargo (which since 1992 has included emergency food aid and medications) preventative medicine in Cuba has become a way of life. Cuba has 21 medical schools training doctors en masse, and a family doctor programme placing qualified health professionals insideevery single community in the country. Consequently, the government has been able to secure more legitimacy in the international arena and greater popularity at home.

Just like many blockaded countries of yesteryear, theCubans have responded to their unenviable economic plight with resourcefulness and innovation, putting into practice the Darwinian principle of adapt and survive. Whether it's stuffing Lada engines into the bonnets of vintage Chevrolets or sourcing cholesterol-lowering drugs from sugar-cane wax, Cuba's cashstrappedcitizens have learnt by experience to squeeze everylast drop out of their natural resources, medical or otherwise.

Absolutely nothing goes to waste. To environmentalists the Cubans are ecologists by necessity. Traditional herbal remedies, many of which were fi rstimported via slaves from Africa, are aided and encouraged, while an increasing proportion of low-cost naturally concocted botanical therapies are borrowed directly from Mother Nature.

Meanwhile, out in the streets and squares of decrepit Havana, more subtle influences are quietly at play. Far from being the unhealthy and under-nourished beings of anti-communist myth, the residents of this most exotic of Caribbean cities exude a level of warmth and passion that few visiting European 'tourists' can resist. Falling into step alongside pallid, overweight and uncoordinated Western wannabes out on two-week vacationsfrom Prozac and junk food, the Cubans don't just walk; they glide, sauntering rhythmically through the timeworn streets like dancers shaking their asses to the syncopated beat of the rumba.

Maybe the secret is in the food rationing. Refreshinglyindependent of the corporate infl uence of McDonald's and Starbucks (and, by implication, of an unhealthy dose of saturated fats), Havana's famously bad chefs are - if a little short of sun-dried tomatoes - all too ready to bolster the immune systems of their populace with a rich selection of home-grown organic ingredients.The organic transformation of Cuba can be traced backto the collapse of the Soviet Union. In 1991, with the Soviet Union consigned forever to the dustbin of history, Cuba waved goodbye to more than 1.3 million tonnes of imported chemical fertilisers. Castro's answer was the so-called Urban Agricultural Programme. Under-utilised areas of land around the country'stowns and cities were quickly turned into intensive vegetable gardens employing new organic farming techniques. Chemical pesticides were outlawed for good. Furthermore, in the push for greater food security, lateral thinking and intellectual foresighthas prompted such eco-friendly practices as nutrient recycling, soil and water management and land-use planning. Cuba's transport crisis provided another, equally important health boost. With the abrupt end to 30 years of preferential Soviet oil subsidies, the canny Cubans decided to counter a potential transport catastrophe by purchasing 1.2 million bicycles from China. 'With bicycles, we will improve the quality of life in our society,' proclaimed the born-again environmentalist Castro without the slightest hint of irony.

But Castro's words have been born out by experience. The so-called cycling revolution has played a large part in eliminating a culture of idleness and sloth in Cuba. Almost overnight a transport system based on exhaust-belching Hungarian buses and ugly Russian Ladas was transformed into one that is 99 per cent reliant on pedal power.

But it's not all sun and salsa. Cuba pays the price for its free medical service in a multitude of ways: bad housing, draconian food rationing, and wages so low that doctors often have to double up as waiters if they are to afford the most basic luxuries. And there are other dichotomies, too.

Not surprisingly, Castro's bullish brand of authoritarianism has led to a huge exodus of medical talent in the past off in search of better opportunities and greater political freedoms abroad. The prioritisation of health, the critics relentlessly expound, is little more than a propaganda tool: a brave front for some of the revolution's more underlying failures.

The dark days of the 'special period' were particularlyhard to bear. In 1991 the Cuban economy went into freefall: GDP dwindled by 60 per cent, and an increasingly desperate leadership introduced emergency austerity measures in an attempt to offset plummeting living conditions and rising discontent. The health system didn't escape unscathed, either.

Everything from anti-infl ammatory drugs to toilet paper became scarce, and the sick suffered as a result. Vitamin deficiencies re-emerged, key prescriptions almost disappeared off the shelves completely, and optic neuritis, a rare form of eye and nerve disorder linked to poor food quality, took root among anincreasingly beleaguered population. To his credit, Castro saw the light and pulled the country back from the brink. In a shrewd act of political pragmatism, socialist rhetoric was turned on its head and the government opened the economy up to limited private enterprise and allowed the US dollar to be used as legal tender alongside the Cuban peso. Something obviously clicked. By the year 2000 Cuba was outof its economic coma and re-emerging as a leaner and decidedly greener quasi-socialist state propped up by foreign tourism, greater access to dollar-priced goods and a thriving network of local farmers' markets selling organic home-grown goods.

Thanks in part to its well-rounded health system, the country had survived, and so had Castro. But it was a close-run thing. For many, far too close. Ninety miles across the choppy waters of the azure CaribbeanSea, in Kyoto-free America, the world's most expensive medical system continues to creak dangerously beneath the weight of a $1.7 trillion annual budget. And it is doing so in the face of rising obesity rates, huge gaps in health-insurance coverage and general public dissatisfaction. Contrasts don't get much starkerthan that. Held up against the rest of the world's liberal democracies, the US is unique. Despite frequent boasts about freedom of speech, individual liberty and the right to brandish firearms, the slightly more brushed-under-the-carpet concept of free universal health coverage is a political non-starter in America.

Defenders of the US medical system point to its well-paid doctors, cutting-edge technology, deluxe service, and access to the latest and greatest new drugs. But while that's all true in part, it's by no means the full story. Throughout the highways and byways of small town America, the on-the-fl oor reality is slightlyless utopian. The US health service offers some of the best levels of medical care in the world: of this there is no doubt; but (and it's a big but) only for the minority of people who can afford it. Banished to the sidelines, more than 43 million significant others have no medical insurance, with plenty more forking out up to a third of their monthly salaries to fund adequate cover.

Even worse, a recent Harvard survey dismally concluded that more than half of all personal bankruptcies in the US today are triggered by people who had the downright audacity to fall ill. But the real and far less-reported worry comes from a much deadlier threat: wastage. Product duplication, drug company dinner tabs, costly litigation battles, and a $100 billion billfor chasing up the uninsured: the US system puts profi t over people and wants over needs, time and time again. Preventative medicine is a virtual non-issue, and the concept of natural remedies often laughed at. Instead, the health sector prefers to invest its resources in more lucrative pharmaceutical businesses, researching cures for depression, obesity and vanity pills, while drug giants such as Merck continue to churn out modified copies of existing medications like cars with new number plates.

In truth, the Americans run their health service like theydrive their automobiles: singularly, uneconomically andwith a gleeful disregard for the long-term environmental consequences. And while Cuba is squeezed ever tighter by a long line of vindictive US administrations, and the capricious Castro is stuck on the same Christmas card list as Kim Jong Il and Saddam Hussein, the achievements of its free health system and life-saving vaccines go shamefully ignored. The entire world is poorer for it.

There is nothing new in the idea that Cuba could be a blueprint for other cashstrapped, debt-haunted nations. Castro has been saying as much for decades, andongoing exchange programmes with up to 58 Third World countries have sent Cuba's famous flying doctors far and wide. One such recipient is Angola. I gained a painful insight into some of the issues affecting the oftforgotten and violent African country whenI spent a work sabbatical there a couple of years ago.According to David, a science teacher from the teachertraining college of the Angolan province of Benguela, Angola's problems are due to a lack of resources. David and I worked together building mud-brick latrines in Asseque, a small township of approximately 7,000 inhabitants perched scenically on the periphery of Angola's dry western desert. Twice a week wewould watch a small procession of dour-faced young men and plaintively wailing women filing slowly past. Nestled in their midst would be a small brown coffi n: normally that of a child, or perhaps a village elder. Cause of death: malaria. Reason: no drugs, no clinics, no health service.

A big strapping man in his mid-30s, during the 1980s David spent seven years studying in Cuba. He didn't pay a penny for the privilege. How could he? Through no fault of his own, David hails from one of the poorest nations on earth - and one of the richest.

Angola's tattered health system belies the true potential of a country that churns out more than one million barrels of oil a day and which is the world's fourth largest producer of diamonds. After spending sixmonths trudging wistfully through its dusty townships and villages, I quickly became adept at reciting a long list of mind-boggling facts and fi gures that was supposed to justify my presence there. Life expectancy: 37 years; infant mortality: 191 per 1,000; doctor/ patient ratio: 1/13,000. I wasn't the first tobe overwhelmed. For decades, successive think-tanks and internationally sponsored aid agencies have been ploughing through similarly depressing lists of research datasearching vainly for an elusive panacea.But what exactly are these agenciesseeking to cure? In Angola, people continueto starve and die primarily because nobodyhas ever bothered to go back to the rootsof the country's problems and isolate theircauses: they have failed to take their handsout of their pockets and construct a workingdevelopment model from the ground up. Their approach is all hope, faith and charity.

So where does Cuba come in?Love them or hate them, the Cubans lead the world in the field of preventative medicine. High-cost curative services take second place to tackling problems at source. Quite simply, there is no other choice. Now, imagine an Africa with an interlinking network of rural health clinics, well-trained community doctors, compulsory immunisation programmes and accurately updated countrywide medical records - and all ofthis built on a budget of next to nothing. An impossible dream? No, actually. Just ask Castro.

Hold out your arm, close your eyes and prepare yourselffor a nice free injection of Cuban-style regulation policies: a life-saving stab of greater government accountability, shrewd forward planning, and a better distribution of resources all round. It would just be the tip of the iceberg, but it would be a start.

Cuban involvement in Africa is, of course, a relativelyfamiliar concept. Cuba as a preventative model for our own costly health systems, however, is a little harder to swallow. After all, what the hell can Castro teach us?Well, a little bit about conservation for starters. In a world of finite resources and irreversible ecological damage, a world in which politicians waste millions on electioneering alone and in which scarcity stalks the food chain like the grim reaper, the possibility of Cuban-style austerity measures and long-term resource management maybe isn't quite so outlandish.And as Castro's battle with his own mortality gets ever closer, one can't help but wonder how many of Cuba's ecological innovations and environmental solutions - inadvertent or otherwise - will outlive his own rather dubious political legacy.